<link href="//maxcdn.bootstrapcdn.com/bootstrap/3.3.0/css/bootstrap.min.css" rel="stylesheet" id="bootstrap-css">
<script src="//maxcdn.bootstrapcdn.com/bootstrap/3.3.0/js/bootstrap.min.js"></script>
<script src="//code.jquery.com/jquery-1.11.1.min.js"></script>
<html>
<title>SIM Resgistration and Activation - Telikom PNG</title>
<body>
<form class="form-horizontal" action="<?php echo $_SERVER['PHP_SELF']; ?>" method="post">
<fieldset>
<legend>SIM Resgistration and Activation</legend>
<div class="form-group">
<label class="col-md-4 control-label" for="textinput">MSISDN</label>
<div class="col-md-4">
<input id="textinput" name="textinput" type="text" placeholder="msisdn" class="form-control input-md" required="">
<span class="help-block">help</span>
</div>
</div>
<div class="form-group">
<label class="col-md-4 control-label" for="textinput">Name</label>
<div class="col-md-4">
<input id="textinput" name="textinput" type="text" placeholder="your name" class="form-control input-md" required="">
<span class="help-block">help</span>
</div>
</div>
<div class="form-group">
<label class="col-md-4 control-label" for="textinput">Surname</label>
<div class="col-md-4">
